Palifermin: Role in the Prevention of Chemotherapy- and Radiation-Induced Mucositis

Mechanisms and Potential Clinical Implications of Oral Microbiome in Oral Squamous Cell Carcinoma

Microorganisms in the oral cavity are abundant in the human body. At present, more than 700 species of oral microorganisms have been identified. Recently, a lot of literature has indicated that the oral microbiota plays an important role in the occurrence, development, and prognosis of oral squamous cell carcinoma (OSCC) through various mechanisms. And researchers are now trying to utilize oral microbiota in cancer diagnosis and treatment. However, few articles systematically summarize the effects of oral microbes in the diagnosis, treatment, and disease outcomes of oral cancer. Herein, we made a summary of the microbial changes at cancerous sites and placed more emphasis on the mechanisms by which the oral microbiome promotes cancerization. Moreover, we aimed to find out the clinical value of the oral microbiome in OSCC.

Nuclear bomb and public health

Since the nuclear bomb attack against Hiroshima and Nagasaki in 1945, the world has advanced in nuclear technology. Today, a nuclear bomb could target a large-scale attack, at a longer range, and with much greater destructive force. People are increasingly concerned about the potential destructive humanitarian outcomes. We discuss actual conditions detonation of an atomic bomb would create, radiation injuries, and diseases. We also address concerns about functionality of medical care systems and other systems that support medical systems (i.e., transport, energy, supply chain, etc. systems) following a massive nuclear attack and whether citizens able to survive this.

Palliative oral care in terminal cancer patients: Integrated review

BACKGROUND

Palliative care (PC) aims to improve quality of life in patients and its families against life threatening diseases, through suffering’s prevention and relief. It is the duty of the dental surgeon to possess the knowledge needed to treat a patient with little life span, in order to establish an adequate treatment plan for each situation.

AIM

To synthesize the published evidence on oral conditions, impact, management and challenges in managing oral conditions among palliative patients.

METHODS

Articles were selected from PubMed and Scopus electronic platforms, using a research strategy with diverse descriptors related to “palliative care”, “cancer” and “oral health”. The article’s selection was done in two phases. The first one was performed by the main researcher through the reading of the abstracts. In the second phase two researchers selected eligible articles after reading in full those previous selected. Data was tabulated and analyzed, obtaining information about what is found in literature related to this subject and what is necessary to be approached in future researches about PC.

RESULTS

As results, the total of 15 articles were eligible, being one a qualitative analysis, 13 (92.8%) clinical trials and one observational study. Of the 15 articles, 8 (53.4%) involved questionnaires, while the rest involved: one systematic review about oral care in a hospital environment, 2 oral exams and oral sample collection, one investigation of terminal patient’s (TP) oral assessment records, 2 collection of oral samples and their respective analysis and one treatment of the observed oral complications.

CONCLUSION

It can be concluded that the oral manifestations in oncologic patients in terminal stage are, oral candidiasis, dry mouth, dysphagia, dysgeusia, oral mucositis and orofacial pain. Determining a protocol for the care of these and other complications of cancer – or cancer therapy – based on scientific evidence with the latest cutting-edge research results is of fundamental importance for the multidisciplinary team that works in the care of patients in PC. To prevent complications and its needed to initial the dentist as early as possible as a multidisciplinary member. It has been suggested palliative care protocol based on the up to date literature available for some frequent oral complications in TP with cancer. Other complications in terminal patients and their treatments still need to have further studying.

Interactions of heparin derivatives with recombinant human keratinocyte growth factor: Structural stability and bioactivity effect study

Heparin and heparan sulfate are important glycosaminoglycans that can regulate the activities of many vital proteins, especially the fibroblast growth factor (FGF) family. Because FGF7 (KGF) has an important role in tissue repair and maintaining the integrity of the mucosal barrier, recombinant human keratinocyte growth factor (rhKGF, palifermin) has been approved for the treatment of wound healing and oral cavity. Due to heparin plays an important role in the KGF signaling pathway, a more detailed study of the drug-drug interactions (DDIs) between rhKGF and heparin at the atomic level and investigating their synergistic effect on each other in terms of biology, especially in silico, is necessary for a better understanding of DDIs. In this study, DDIs between rhKGF and low-molecular weight heparin types (LMWH) were investigated. In this regard, scrutiny of the influence of the synergistic heparin types on the structure and biostability of rhKGF is accomplished using computational methods such as molecular docking and molecular dynamic simulations (MDs). Subsequently, the motion behavior of rhKGF in interaction with LMWHs was evaluated based on eigenvectors by using principal component analysis (PCA). Also, the binding free energies of rhKGF-LMWH complexes were calculated by the molecular mechanics/Poisson-Boltzmann surface area (MM-BPSA) method. The result showed that rhKGF-idraparinux (-6.9 kcal/mol) and rhKGF-heparin (-6.0 kcal/mol) complexes had significant binding affinity as well as they had a more stable binding to rhKGF than to other LMWH during 100 ns simulation. However, in order to confirm the curative effect of these drugs, clinical trials must be done.

Looking for the phoenix: the current research on radiation countermeasures

PURPOSE

Ionizing radiation (IR) is widely applied in radiotherapy for the treatment of over 50% of cancer patients. IR is also intensively used in medical diagnostics on a daily basis in imaging. Moreover, recent geopolitical events have re-ignited the real threat of the use of nuclear weapons. Medical radiation countermeasures represent one of the effective protection strategies against the effects of IR. The aim of this review was to summarize the most commonly used strategies and procedures in the development of radiation countermeasures and to evaluate the current state of their research, with a focus on those in the clinical trial phase.

METHODS

Clinical trials for this review were selected in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. The search was performed in the clinicaltrials.gov database as of May 2022.

RESULTS

Our search returned 263 studies, which were screened and of which 25 were included in the review. 10 of these studies had been completed, 3 with promising results: KMRC011 increased G-CSF, IL-6, and neutrophil counts suggesting potential for the treatment of hematopoietic acute radiation syndrome (H-ARS); GC4419 reduced the number of patients with severe oral mucositis and its duration; the combination of enoxaparin, pentoxifylline, and ursodeoxycholic acid reduced the incidence of focal radiation-induced liver injury.

CONCLUSION

The agents discovered so far show significant side effects or low efficacy, and hence most of the tested agents terminate in the early stages of development. In addition, the low profitability of this type of drug demotivates the private sector to invest in such research. To overcome this problem, there is a need to involve more public resources in funding. Among the technological opportunities, a deeper use of in silico approaches seems to be prospective.

Fibroblast growth factor 7 alleviates myocardial infarction by improving oxidative stress via PI3Kα/AKT-mediated regulation of Nrf2 and HXK2

Acute myocardial infarction (MI) triggers oxidative stress, which worsen cardiac function, eventually leads to remodeling and heart failure. Unfortunately, effective therapeutic approaches are lacking. Fibroblast growth factor 7 (FGF7) is proved with respect to its proliferative effects and high expression level during embryonic heart development. However, the regulatory role of FGF7 in cardiovascular disease, especially MI, remains unclear. FGF7 expression was significantly decreased in a mouse model at 7 days after MI. Further experiments suggested that FGF7 alleviated MI-induced cell apoptosis and improved cardiac function. Mechanistic studies revealed that FGF7 attenuated MI by inhibiting oxidative stress. Overexpression of FGF7 actives nuclear factor erythroid 2-related factor 2 (Nrf2) and scavenging of reactive oxygen species (ROS), and thereby improved oxidative stress, mainly controlled by the phosphatidylinositol-3-kinase α (PI3Kα)/AKT signaling pathway. The effects of FGF7 were partly abrogated in Nrf2 deficiency mice. In addition, overexpression of FGF7 promoted hexokinase2 (HXK2) and mitochondrial membrane translocation and suppressed mitochondrial superoxide production to decrease oxidative stress. The role of HXK2 in FGF7-mediated improvement of mitochondrial superoxide production and protection against MI was verified using a HXK2 inhibitor (3-BrPA) and a HXKII VDAC binding domain (HXK2VBD) peptide, which competitively inhibits localization of HXK2 on mitochondria. Furthermore, inhibition of PI3Kα/AKT signaling abolished regulation of Nrf2 and HXK2 by FGF7 upon MI. Together, these results indicate that the cardio protection of FGF7 under MI injury is mostly attributable to its role in maintaining redox homeostasis via Nrf2 and HXK2, which is mediated by PI3Kα/AKT signaling.

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The expression of FGF7 in cardiomyocytes is decreased upon myocardial infarction (MI).

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Overexpression of FGF7 in the heart protects against cardiomyocytes apoptosis in a rodent model of MI.

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FGF7 attenuates MI-induced cardiac apoptosis via maintaining redox homeostasis.

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FGF7 maintains redox homeostasis by promoting mitochondrial HXK2 localization and Nrf2 nuclear translocation.

Noninvasive Systemic Modalities for Prevention of Head and Neck Radiation-Associated Soft Tissue Injury: A Narrative Review

BACKGROUND

 Radiation-associated soft tissue injury is a potentially devastating complication for head and neck cancer patients. The damage can range from minor sequelae such as xerostomia, which requires frequent daily maintenance, to destructive degenerative processes such as osteoradionecrosis, which can contribute to flap failure and delay or reverse oral rehabilitation. Despite the need for effective radioprotectants, the literature remains sparse, primarily focused on interventions beyond the surgeon's control, such as maintenance of good oral hygiene or modulation of radiation dose.

METHODS

 This narrative review aggregates and explores noninvasive, systemic treatment modalities for prevention or amelioration of radiation-associated soft tissue injury.

RESULTS

 We highlighted nine modalities with the most clinical potential, which include amifostine, melatonin, palifermin, hyperbaric oxygen therapy, photobiomodulation, pentoxifylline-tocopherol-clodronate, pravastatin, transforming growth factor-β modulators, and deferoxamine, and reviewed the benefits and limitations of each modality. Unfortunately, none of these modalities are supported by strong evidence for prophylaxis against radiation-associated soft tissue injury.

CONCLUSION

 While we cannot endorse any of these nine modalities for immediate clinical use, they may prove fruitful areas for further investigation.

"Radio-Protective Effect of Aminocaproic Acid in Human Spermatozoa"

BACKGROUND

The negative effects of ionizing radiation on organs and the reproductive system are well known and documented. Exposure to gamma radiation can lead to oligospermia, azoospermia and DNA damage. Up to date, there is no effective pharmaceutical compound for protecting the male reproductive system and sperm.

OBJECTIVE

This study aimed at investigating the ability of Ɛ-aminocaproic acid (EACA) to prevent the damage of human spermatozoa and DNA induced by ionizing radiation.

MATERIALS AND METHODS

Sperm samples were obtained from healthy volunteers (35 men; 31.50 ± 7.34 years old). There were 4 experimental groups: 1) control group (CG), 2) group exposed to maximal radiation dose 67.88 mGy (RMAX), 3) low-dose radiation (minimal) 22.62 mGy (RMIN), and 4) group treated with radiation (67.88 mGy) and EACA (dose 50 ng/ml). Sperm motility, viability, and DNA damage were assessed.

RESULTS

We observed a significant decrease in total sperm motility of the RMAX group compared to CG (p < 0.05). Sperm viability in the RMAX group was also reduced in comparison to the control (p < 0.05). A significant increase in DNA fragmentation was detected in the RMAX group. The results demonstrated that the treatment of sperm with EACA led to a decrease in the fragmentation of the sperm DNA (compared to the RMAX group) (p < 0.05).

CONCLUSION

The results indicate that EACA effectively protects human spermatozoa from DNA damage induced by ionizing radiation. Treatment of spermatozoa with EACA led to the preservation of cell motility, viability, and DNA integrity upon radiation exposure.

MultiPep: a hierarchical deep learning approach for multi-label classification of peptide bioactivities

Peptide-based therapeutics are here to stay and will prosper in the future. A key step in identifying novel peptide-drugs is the determination of their bioactivities. Recent advances in peptidomics screening approaches hold promise as a strategy for identifying novel drug targets. However, these screenings typically generate an immense number of peptides and tools for ranking these peptides prior to planning functional studies are warranted. Whereas a couple of tools in the literature predict multiple classes, these are constructed using multiple binary classifiers. We here aimed to use an innovative deep learning approach to generate an improved peptide bioactivity classifier with capacity of distinguishing between multiple classes. We present MultiPep: a deep learning multi-label classifier that assigns peptides to zero or more of 20 bioactivity classes. We train and test MultiPep on data from several publically available databases. The same data are used for a hierarchical clustering, whose dendrogram shapes the architecture of MultiPep. We test a new loss function that combines a customized version of Matthews correlation coefficient with binary cross entropy (BCE), and show that this is better than using class-weighted BCE as loss function. Further, we show that MultiPep surpasses state-of-the-art peptide bioactivity classifiers and that it predicts known and novel bioactivities of FDA-approved therapeutic peptides. In conclusion, we present innovative machine learning techniques used to produce a peptide prediction tool to aid peptide-based therapy development and hypothesis generation.

Fabrication and Evaluation of Transdermal Microneedles for a Recombinant Human Keratinocyte Growth Factor

Objectives

Microneedle transdermal patches are a combination of hypodermic needles and transdermal patches used to overcome the individual limitations of both injections and patches. The objective of this study was to design a minimally invasive, biodegradable polymeric recombinant human keratinocyte growth factor (rHuKGF) microneedle array and evaluate the prepared biodegradable microneedles using in vitro techniques.

Materials and Methods

Biodegradable polymeric microneedle arrays were fabricated out of poly lactic-co-glycolic acid (PLGA) using the micromolding technique under aseptic conditions, and the morphology of the microneedles was characterized using light microscopy. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis was used to rule out drug-polymer interactions. Standard procedures were used to analyze the prepared microneedle arrays for in vitro drug release and to perform a microneedle insertion test. Enzyme-linked immunosorbent assay was used to quantify rHuKGF.

Results

The PLGA polymer was safe for use in the fabrication of rHuKGF microneedles as there was no interaction between the drug and the polymer. The fabricated rHuKGF microneedle arrays had fully formed microneedles with a height of 600 µm and a base of 300 µm. The drug from the microneedle patch was released in vitro within 30 minutes. The strength of the microneedles in the patch was good, as they were able to reach a depth of 381±3.56 µm into parafilm without any structural change or fracture.

Conclusion

Microneedle transdermal patches were successfully prepared for rHuKGF, and their evaluation suggested excellent quality and uniformity of patch characteristics. This can have potential applications in the therapeutic arena, offering advantages in terms of reduced dosing frequency, improved patient compliance, and bioavailability.

A New Insight on the Radioprotective Potential of Epsilon-Aminocaproic Acid

Background and objectives: The aim of the study was to scrutinize the ability of epsilon-aminocaproic acid (EACA) to prevent radiation-induced damage to human cells. Materials and Methods: Human peripheral blood mononuclear cells (PBMCs) were exposed to ionizing radiation at three low doses (22.62 mGy, 45.27 mGy, and 67.88 mGy) in the presence of EACA at the concentration of 50 ng/mL. Results: EACA was able to prevent cell death induced by low-dose X-ray radiation and suppress the formation of reactive oxygen species (ROS). EACA also demonstrated a capacity to protect DNA from radiation-induced damage. The data indicated that EACA is capable of suppression of radiation-induced apoptosis. Comparative tests of antioxidative activity of EACA and a range of free radical scavengers showed an ability of EACA to effectively inhibit the generation of ROS. Conclusions: This study showed that the pretreatment of PBMCs with EACA is able to protect the cells from radiation-elicited damage, including free radicals' formation, DNA damage, and apoptosis.

Modulation of Caspase-3 activity using a redox active vitamin K3 analogue, plumbagin, as a novel strategy for radioprotection

Radiation induced damage to normal cells is a major shortcoming of conventional radiotherapy, which necessitates the development of novel radio-protective drugs. An ideal radio-modulator would protect normal cells while having cytotoxic effects on cancer cells. Plumbagin is a potent anti-tumour agent and has been shown to sensitize tumour cells to radiation-induced damage. In the present study, we have evaluated the radio-protective potential of plumbagin and found that it protected normal lymphocytes against radiation-induced apoptosis, but did not protect cancer cells against radiation. Plumbagin offered radioprotection even when it was added to cells after irradiation. The ability of only thiol based antioxidants to abrogate the radio-protective effects of plumbagin suggested a pivotal role of thiol groups in the radio-protective activity of plumbagin. Further, protein interaction network (PIN) analysis was used to predict the molecular targets of plumbagin. Based on the inputs from plumbagin's PIN and in light of its well-documented ability to modulate thiol groups, we proposed that plumbagin may act via modulation of caspase enzyme which harbours a critical catalytic cysteine. Indeed, plumbagin suppressed radiation-induced increase in homogenous caspase and caspase-3 activity in lymphocytes. Plumbagin also inhibited the activity of recombinant caspase-3 and mass spectrometric analysis revealed that plumbagin covalently interacts with caspase-3. Further, the in vivo radioprotective efficacy of plumbagin (single dose of 2mg/kg body weight) was demonstrated by its ability to rescue mice against radiation (7.5 Gy; Whole Body Irradiation) induced mortality. These results indicate that plumbagin prevents radiation induced apoptosis specifically in normal cells by inhibition of caspase-3 activity.

Role of drugs in the prevention and amelioration of radiation induced toxic effects

As the use of radiation technology for nuclear warfare or for the benefits of mankind (e.g. in radiotherapy or radio-diagnosis) is increasing tremendously, the risk of associated side effects is becoming a cause of concern. These effects, ranging from nausea/vomiting to death, may result from accidental or deliberate exposure and begin in seconds. Through this review paper, efforts have been done to critically review different compounds which have been investigated as radioprotectors and radiation mitigators. Radioprotectors are compounds which are administered just before or at the time of irradiation so as to minimize the radiation induced damage to normal tissues. And radiation mitigators are the compounds which can even minimize or ameliorate post irradiaion-toxicity provided they are administered before the onset of toxic symptoms. A variety of agents have been investigated for their preventive and ameliorative potential against radiation induced toxic effects. This review article has focused on various aspects of the promising representative agents belonging to different classes of radioprotectors and mitigators. Many compounds have shown promising results, but till date only amifostine and palifermin are clinically approved by FDA. To fill this void in pharmacological armamentarium, focus should be shifted towards novel approaches.

Dusquetide: Reduction in oral mucositis associated with enduring ancillary benefits in tumor resolution and decreased mortality in head and neck cancer patients

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Dusquetide was well-tolerated during treatment and throughout the 12-month follow-up.

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Dusquetide did not interfere with tumor treatment.

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Dusquetide treated groups had less mortality that placebo treated groups through the 12-month follow-up.

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Dusquetide treated groups had fewer “non-fungal” infections than placebo treated groups.

Innate immunity is a key component in the pathogenesis of oral mucositis, a universal toxicity of chemoradiation therapy (CRT). Dusquetide, a novel Innate Defense Regulator, has demonstrated both nonclinical and clinical efficacy in ameliorating severe oral mucositis (SOM). Long term follow-up studies from the Phase 2 clinical study evaluating dusquetide as a treatment for SOM in head and neck cancer (HNC) patients receiving CRT have now been completed. Extended analysis indicates that dusquetide therapy was well-tolerated and did not contribute to increased infection, tumor growth or mortality. Potential ancillary benefits of duquetide therapy were also identified.

Dusquetide: A novel innate defense regulator demonstrating a significant and consistent reduction in the duration of oral mucositis in preclinical data and a randomized, placebo-controlled phase 2a clinical study

Dusquetide, a novel Innate Defense Regulator, modulates the innate immune system at a key convergence point in intracellular signaling pathways and has demonstrated activity in both reducing inflammation and increasing clearance of bacterial infection. Innate immunity has also been implicated in the pathogenesis of oral mucositis (OM), a universal toxicity of chemoradiation therapy (CRT). Testing the hypothesis that dusquetide can mitigate the development and duration of OM, preclinical studies have been completed and correlated with interim results from a Phase 2 clinical study in patients undergoing CRT for head and neck cancer. Dusquetide reduced the duration of OM in mouse and hamster models by approximately 50%, which was recapitulated by the 50% reduction of severe OM (SOM) in the Phase 2 trial. A reduction in the clinical rate of infection was also observed, consistent with previously reported preclinical studies. In aggregate, these results not only demonstrate the safety and efficacy of dusquetide in addressing this unmet medical need, but also provide proof of concept for the translation of dusquetide action between animal models and the human clinical setting, and further support the contention that innate immunity is an important driver for the initiation and continued impact of OM.

Honey prevents oral mocositis in children undergoing chemotherapy: A quasi-experimental study with a control group

BACKGROUND

There are numerous pharmacological and non-pharmacological treatment options available in the treatment of oral mucositis. However, in spite of so many methods and products, medical professionals have not come to a consensus as to which of these offer the best results.

OBJECTIVES

This study was conducted to assess the effect of oral care with honey on children undergoing chemotherapy for the prevention and healing of oral mucositis.

METHODS

This quasi-experimental study was conducted on children undergoing chemotherapy. The study group consisted of 83 children who attended clinics and polyclinics for chemotherapy. All the children were included in the study period. The study was completed with a total of 76 children except for seven patients who were excluded from the study. The data were collected using a form and the World Health Organization Mucositis Assessment Index. The data were analyzed using percentage distributions, means, a chi-square test, a t-test, a variance analysis, and a Friedman test. Ethics approval of the study was obtained from the Institution Ethics Committee.

RESULTS

It was found that the severity of oral mucositis in the children in the experimental group was significantly less than the control group. The mucositis recovery period in the experimental group was significantly shorter than the control group.

CONCLUSION

Regular oral care with honey for children undergoing chemotherapy for hematological cancers prevents mucositis and also accelerates recovery of it when started after mucositis onset.

Interventions for preventing oral mucositis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent them. One of these side effects is oral mucositis (mouth ulcers).

OBJECTIVES

To evaluate the effectiveness of prophylactic agents for oral mucositis in patients with cancer receiving treatment, compared with other potentially active interventions, placebo or no treatment.

SEARCH STRATEGY

Electronic searches of Cochrane Oral Health Group and PaPaS Trials Registers (to 16 February 2011), CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE via OVID (1950 to 16 February 2011), EMBASE via OVID (1980 to 16 February 2011), CINAHL via EBSCO (1980 to 16 February 2011), CANCERLIT via PubMed (1950 to 16 February 2011), OpenSIGLE (1980 to 2005) and LILACS via the Virtual Health Library (1980 to 16 February 2011) were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information.

SELECTION CRITERIA

Randomised controlled trials of interventions to prevent oral mucositis in patients receiving treatment for cancer.

DATA COLLECTION AND ANALYSIS

Information regarding methods, participants, interventions, outcome measures, results and risk of bias were independently extracted, in duplicate, by two review authors. Authors were contacted for further details where these were unclear. The Cochrane Collaboration statistical guidelines were followed and risk ratios calculated using random-effects models.

MAIN RESULTS

A total of 131 studies with 10,514 randomised participants are now included. Overall only 8% of these studies were assessed as being at low risk of bias. Ten interventions, where there was more than one trial in the meta-analysis, showed some statistically significant evidence of a benefit (albeit sometimes weak) for either preventing or reducing the severity of mucositis, compared to either a placebo or no treatment. These ten interventions were: aloe vera, amifostine, cryotherapy, granulocyte-colony stimulating factor (G-CSF), intravenous glutamine, honey, keratinocyte growth factor, laser, polymixin/tobramycin/amphotericin (PTA) antibiotic pastille/paste and sucralfate.

AUTHORS' CONCLUSIONS

Ten interventions were found to have some benefit with regard to preventing or reducing the severity of mucositis associated with cancer treatment. The strength of the evidence was variable and implications for practice include consideration that benefits may be specific for certain cancer types and treatment. There is a need for further well designed, and conducted trials with sufficient numbers of participants to perform subgroup analyses by type of disease and chemotherapeutic agent.

Palifermin-induced acral erythrodysaesthesia variant in the treatment of acute myeloid leukaemia

The recombinant human keratinocyte growth factor, palifermin, offers a potential means of reducing or preventing mucositis in patient undergoing intensive cancer treatments. This case report details the development of acral erythrodysaesthesia in one patient who underwent palifermin treatment prior to high-intensity re-induction chemotherapy for acute myeloid leukaemia.

Adverse effects of drugs on the esophagus

Given the function of the esophagus to transport orally ingested solids and liquids into the stomach there are several medications with adverse effect on esophageal structures and function. Various pharmacologic agents can induce esophageal injury, promote gastroesophageal reflux by decreasing lower esophageal sphincter tone or affect esophageal perception and motility. The risks of bisphosphonates, doxycycline, ferrous sulfate, ascorbic acid, aspirin/NSAIDs and chemotherapeutic agents to induce esophageal lesions have been documented in case reports and short series. In addition to direct mucosal injury, many commonly used medications including nitroglycerins, anticholinergics, beta-adrenergic agonists, aminophyllines, and benzodiazepines promote/facilitate gastroesophageal reflux by reducing lower esophageal sphincter pressure. Additional evidence accumulates on the adverse effects of various medications on esophageal motility and perception. The treatment of medication-induced esophageal lesions includes (1) identifying and discontinuing the causative medication, (2) promoting healing of esophageal injury by decreasing esophageal acid exposure or coating already existing esophageal lesions, (3) eventual use of protective compounds.

Infectious complication in 314 patients after high-dose therapy and autologous hematopoietic stem cell transplantation: risk factors analysis and outcome

BACKGROUND

Infectious complications occur in most of the patients receiving high-dose therapy (HDT) and autologous hematopoietic stem cell transplantation (HSCT). The objective of the study was to analyze of the type and incidence of infectious complications during neutropenia after HDT and autologous HSCT with respect to risk factors related to stem cell transplant setting in patients treated for hematological malignancies in a single center.

PATIENTS AND METHODS

A total number of 314 patients diagnosed for Hodgkin's disease (HD), non-Hodgkin's lymphoma (NHL), acute myeloid leukemia (AML), multiple myeloma (MM) or acute lymphoblastic leukemia (ALL) were included in the study. Analysis of risk factors and outcome of infections after HDT and autologous HSCT was performed.

RESULTS

Infectious complications during neutropenia after HDT occurred in 92.3% patients. Microbiologically documented infections (MDI) accounted for 38.9% of febrile episodes, clinically documented infections (CDI) for 9.3%, and fever of unknown origin (FUO) for 51.7% cases. Median time to defervescence with antibiotic therapy was seven days for FUO and nine days for documented infections (p < 0.001). Duration of infection correlated with the length of very severe neutropenia (p < 0.001). Response to first-line antibiotic therapy was seen in 34% patients. Infections were fatal in 12 (3.8%) patients. The highest probability of infection was observed for ALL and AML patients, especially these conditioned with total body irradiation (TBI).

CONCLUSION

Patients at high risk of infection after autologous HSCT were identified as those with acute leukemia and those after conditioning with TBI, all with prolonged neutropenia. We suggest that newer prophylactic strategies should be administered to these groups of patients.

Multimodality therapy for locally advanced cervical carcinoma: state of the art and future directions

Globally, cervical cancer is the second most common cause of cancer-related mortality among women causing approximately 234,000 deaths annually among developing countries and killing 40,000 in developed nations. Most of these deaths occur in women with bulky or locally advanced cervical cancer, International Federation of Gynecology and Obstetrics (FIGO) stages IIB through IVA, when lesions are not amenable to high cure rates with surgery or radiation (RT). The standard prescription for RT used to treat locally advanced cervical cancer has been dictated by common practice and patterns of care studies. In contrast, the addition of concomitant chemotherapy to RT has been studied in a number of randomized prospective trials, which are discussed in detail. When added to RT, cisplatin reduces the relative risk of death from cervical carcinoma by approximately 50% by decreasing local/pelvic failure and distant metastases. In 1999, weekly intravenous cisplatin at 40 mg/m2 for 6 weeks in combination with RT was established as a new standard for the treatment of locally advanced cervical carcinoma. More recently, this recommendation has been expanded to include women with FIGO stage IB2 lesions as well as those with bulky stage IIA cancers. This monograph reviews the state of the art in treating locally advanced cervical cancer with combined chemotherapy and RT and discusses clinical and pathologic prognostic factors that impact cure. Quality of life during and after multimodality therapy is considered as well as ongoing clinical trials and future directions.

Palifermin for patients with haematological malignancies: shifting nursing practice from symptom relief to prevention of oral mucositis

Oral mucositis (OM) is an extremely debilitating side effect of certain high-dose chemotherapy and radiotherapy regimens. It is especially prevalent in patients with haematological malignancies who undergo myeloablative therapy and autologous haematopoietic stem cell transplantation (HSCT). Severe erosion of the lining of the oral cavity can make patients' everyday activities, including eating, drinking, swallowing, and talking, difficult or even impossible. Palifermin (Kepivance) was approved in Europe in 2005 for both prevention and treatment of this painful condition. It works at the epithelial level to help protect cells in the mouth and throat from the damage caused by chemotherapy and radiation, and to stimulate growth and development of new epithelial cells to build up the mucosal barrier. In the pivotal clinical trial, palifermin reduced the incidence, severity, and duration of severe OM. Palifermin was also well-tolerated; common adverse reactions reported included rash, pruritus, erythema, edema, pain, fever, arthralgia, mouth or tongue disorders, and taste alteration. In this article, nurses who are skilled in caring for patients undergoing HSCT review their clinical experience with palifermin, sharing practical advice about its reconstitution, dosing, and administration. By familiarising themselves with the use of palifermin, nurses can influence a shift in clinical practice away from OM symptom management to the more satisfactory situation of protecting patients against severe OM.